Fear...
heart palpitations...terror, a sense of impending doom...dizziness...fear of fear. The
words used to describe panic disorder are often frightening. But there is great hope:
Treatment can benefit virtually everyone who has this condition. It is extremely important
for the person who has panic disorder to learn about the problem and the availability of
effective treatments and to seek help.

The encouraging progress in the treatment of panic disorder reflects recent, rapid
advances in scientific understanding of the brain. In fact, the President and the U.S.
Congress have declared the 1990s the Decade of the Brain.

What is Panic Disorder?

In panic disorder, brief episodes of intense fear are accompanied by multiple physical
symptoms (such as heart palpitations and dizziness) that occur repeatedly and unexpectedly
in the absence of any external threat. These panic attacks, which are the
hallmark of panic disorder, are believed to occur when the brains normal mechanism
for reacting to a threat-the so-called fight or flight response-becomes
inappropriately aroused. Most people with panic disorder also feel anxious about the
possibility of having another panic attack and avoid situations in which they believe
these attacks are likely to occur. Anxiety about another attack, and the avoidance it
causes, can lead to disability in panic disorder.

Who Has Panic Disorder?

In
the United States, 1.6 percent of the adult population, or more than 3 million people,
will have panic disorder at some time in their lives. The disorder typically begins in
young adulthood, but older people and children can be affected. Women are affected twice
as frequently as men. While people of all races and social classes can have panic
disorder, there appear to be cultural differences in how individual symptoms are
expressed.

Symptoms and Course of Panic Disorder

Initial panic attack. Typically, a first panic attack seems to come out of the
blue, occurring while a person is engaged in some ordinary activity like driving a
car or walking to work. Suddenly, the person is struck by a barrage of frightening and
uncomfortable symptoms. These symptoms often include terror, a sense of unreality, or a
fear of losing control.

Panic Attack Symptoms

During
a panic attack, some or all of the following symptoms occur:

Terror-a sense that something
unimaginably horrible is about to happen and one is powerless to prevent it

This
barrage of symptoms usually lasts several seconds, but may continue for several minutes.
The symptoms gradually fade over the course of about an hour. People who have experienced
a panic attack can attest to the extreme discomfort they felt and to their fear that
they had been stricken with some terrible, life-threatening disease or were going
crazy. Often people who are having a panic attack seek help at a hospital emergency
room.

Initial
panic attacks may occur when people are under considerable stress, from an overload of
work, for example, or from the loss of a family member or close friend. The attacks may
also follow surgery, a serious accident, illness, or childbirth. Excessive consumption of
caffeine or use of cocaine or other stimulant drugs or medicines, such as the stimulants
used in treating asthma, can also trigger panic attacks.

Nevertheless
panic attacks usually take a person completely by surprise. This unpredictability is one
reason they are so devastating. Sometimes people who have never had a panic attack assume
that panic is just a matter of feeling nervous or anxious- the sort of feelings that
everyone is familiar with. In fact, even though people who have panic attacks may not show
any outward signs of discomfort, the feelings they experience are so overwhelming and
terrifying that they really believe they are going to die, lose their minds, or be totally
humiliated. These disastrous consequences dont occur , but they seem quite likely to
the person who is suffering a panic attack.

Some
people who have one panic attack, or an occasional attack, never develop a problem serious
enough to affect their lives. For others, however, the attacks continue and cause much
suffering.

Panic
disorder. In panic disorder, panic attacks recur and the person develops an intense
apprehension of having another attack. As noted earlier, this fear-called anticipatory anxiety or fear of fear-can be present most of the time and
seriously interfere with the persons life even when a panic attack is not in
progress. In addition, the person may develop irrational fears called phobias about situations where a panic attack has
occurred. For example, someone who has had a panic attack while driving may be afraid to
get behind the wheel again, even to drive to the grocery store.

People
who develop these panic-induced phobias will tend to avoid situations that they fear will
trigger a panic attack, and their lives may be increasingly limited as a result. Their
work may suffer because they cant travel or get to work on time. Relationships may
be strained or marred by conflict as panic attacks, or the fear of them, rule the affected
person and those close to them.

Also,
sleep may be disturbed because of panic attacks that occur at night, causing the person to
awaken in a state of terror. The experience is so harrowing that some people who have
nocturnal panic attacks become afraid to go to sleep and suffer from exhaustion. Also,
even if there are no nocturnal panic attacks, sleep may be disturbed because of chronic,
panic-related anxiety.

Many
people with panic disorder remain intensely concerned about their symptoms even after an
initial visit to a physician yields no indication of a life-threatening condition. They
may visit a succession of doctors seeking medical treatment for what they believe is a
heart disease or respiratory problem. Or their symptoms may make them think they have a
neurological disorder or some serious gastrointestinal condition. Some patients see as
many as 10 doctors and undergo a succession of expensive and unnecessary tests in the
effort to find out what is causing their symptoms.

This
search for medical help may continue a long time, because physicians who see these
patients frequently fail to diagnose panic disorder. When doctors do recognize the
condition, they sometimes explain it in terms that suggest it is of no importance or not
treatable. For example, the doctor may say, Theres nothing to worry about,
youre just having a panic attack or Its just nerves.
Although meant to be reassuring, such words can be dispiriting to the worried patient
whose symptoms keep recurring. The patient needs to know that the doctor acknowledges the
disabling nature of panic disorder and that it can be treated effectively.

Agoraphobia.
Panic disorder may progress to a more advanced stage in which the person becomes afraid of
being in any place or situation where escape might be difficult or help unavailable in the
event of a panic attack. This condition is called agoraphobia.
It affects about a third of all people with panic disorder.

Typically,
people with agoraphobia fear being in crowds, standing in line, entering shopping malls,
and riding in cars or public transportation. Often, these people restrict themselves to a
zone of safety that may include only the home or the immediate neighborhood.
Any movement beyond the edges of this zone creates mounting anxiety. Sometimes a person
with agoraphobia is unable to leave home alone, but can travel if accompanied by a
particular family member or friend. Even when they restrict themselves to safe
situations, most people with agoraphobia continue to have panic attacks at least a few
times a month.

People
with agoraphobia can be seriously disabled by their condition. Some are unable to work,
and they may need to rely heavily on other family members, who must do the shopping and
run all the household errands, as well as accompany the affected person on rare excursions
outside the safety zone. Thus, the person with agoraphobia typically
leads a life of extreme dependency as well as great discomfort.

Treatment for Panic Disorder

Treatment
can bring significant relief to 70 to 90 percent of people with panic disorder, and early
treatment can help keep the disease from progressing to the later stages where agoraphobia
develops.

Before
undergoing any treatment for panic disorder, a person should undergo a thorough medical
examination to rule out other possible causes of the distressing symptoms. This is
necessary because a number of other conditions, such as excessive levels of thyroid
hormone, certain types of epilepsy, or cardiac arrhythmias, which are disturbances
in the rhythm of the heartbeat, can cause symptoms resembling those of panic disorder.

Several
effective treatments have been developed for panic disorder and agoraphobia. In
1991, a conference held at the National Institutes of Health (NIH) surveyed the available
information on panic disorder and its treatment. The conferees concluded that a form of
psychotherapy and medications are both effective for panic disorder. A treatment should be
selected according to the individual needs and preferences of the patient, the panel said,
and any treatment that fails to produce an effect within 6 to 8 weeks should be
reassessed.

Cognitive-behavioral
therapy. This is a combination of cognitive
therapy, which can modify or eliminate thought patterns contributing to the
patients symptoms, and behavioral therapy,
which aims to help the patient change his or her behavior.

Typically the patient undergoing cognitive-behavioral therapy meets with a therapist for 1
to 3 hours a week. In the cognitive portion of the therapy, the therapist usually conducts
a careful search for the thoughts and feelings that accompany the panic attacks. These
mental events are discussed in terms of the cognitive model of panic attacks.

The
cognitive model states that individuals with panic disorder often have distortions in
their thinking, of which they may be unaware, and these may give rise to a cycle of fear.
The cycle is believed to operate this way: First the individual feels a potentially
worrisome sensation such as an increasing heart rate, tightened chest muscles, or a queasy
stomach. This sensation may be triggered by some worry, an unpleasant mental image, a
minor illness, or even exercise. The person with panic disorder responds to the sensation
by becoming anxious. The initial anxiety triggers still more unpleasant sensations, which
in turn heighten anxiety, giving rise to catastrophic thoughts. The person thinks I
am having a heart attack or I am going insane, or some similar thought.
As the vicious cycle continues, a panic attack results. The whole cycle might take only a
few seconds, and the individual may not be aware of the initial sensations or thoughts.

Proponents
of this theory point out that, with the help of a skilled therapist, people with panic
disorder often can learn to recognize the earliest thoughts and feelings in this sequence
and modify their responses to them. Patients are taught that typical thoughts such as
That terrible feeling is getting worse! or Im going to have a
panic attack or Im going to have a heart attack can be replaced
with substitutes such as Its only uneasiness-it will pass that help to
reduce anxiety and ward off a panic attack. Specific procedures for accomplishing this are
taught. By modifying thought patterns in this way, the patient gains more control over the
problem.

Often
the therapist will provide the patient with simple guidelines to follow when he or she can
feel that a panic attack is approaching. One therapist has offered a set of strategies
that have helped some of her patients to cope with panic attacks. Jerilyn Ross suggests
the following strategies.

Strategies for Coping with Panic

Remember that although your
feelings and symptoms are very frightening, they are not dangerous or harmful.

Understand that what you are
experiencing is just an

exaggeration of your normal bodily reactions to stress.

Do not fight your feelings or
try to wish them away. The more you are willing to face them, the less intense they will
become.

Stay in the present. Notice
what is really happening to you as opposed to what you think might happen.

Label your fear level from zero
to ten and watch it go up and

down. Notice that it does not stay at a very high level for
more than a few seconds.

When you find yourself thinking
about the fear, change your what if thinking. Focus on and carry out a simple
and manageable task such as counting backwards from 100 by 3s or snapping a rubber
band on your wrist.

Notice that when you stop
adding frightening thoughts to your

fear, it begins to fade.

When the fear comes, expect and
accept it. Wait and give it time to pass without running away from it.

Be proud of yourself for your
progress thus far, and think about

how good you will feel when you succeed this time.

In cognitive therapy, discussions between the patient and the therapist are not normally
focused on the patients past, as is the case with some forms of psychotherapy.
Instead, conversations focus on the difficulties and successes the patient is having at
the present time, and on skills the patient needs to learn. The behavioral portion of
cognitive-behavioral therapy may involve systematic training in relaxation techniques. By
learning to relax, the patient may acquire the ability to reduce generalized anxiety and
stress that often sets the stage for panic attacks.

Breathing exercises are often included in the behavioral therapy. The patient learns
to control his or her breathing and avoid hyperventilation-a
pattern of rapid, shallow breathing that can trigger or exacerbate some peoples
panic attacks.

Another
important aspect of behavioral therapy is exposure to internal sensations called interoceptive exposure. During interoceptive
exposure the therapist will do an individual assessment of internal sensations associated
with panic. Depending on the assessment, the therapist may then encourage the patient to
bring on some of the sensations of a panic attack by, for example, exercising to increase
heart rate, breathing rapidly to trigger lightheadedness and respiratory symptoms, or
spinning around to trigger dizziness. Exercises to produce feelings of unreality may also
be used. Then the therapist teaches the patient to cope effectively with these sensations
and to replace alarmist thoughts such as I am going to die, with more
appropriate ones, such as Its just a little dizziness-I can handle it.

Another
important aspect of behavioral therapy is in-vivo
or real-life exposure. The therapist and the
patient determine whether the patient has been avoiding particular places and situations,
and which patterns of avoidance are causing the patient problems. They agree to work on
the avoidance behaviors that are the most seriously interfering with the patients
life. For example, fear of driving may be of paramount importance for one patient, while
inability to go to the grocery store may be most handicapping for another.

Some
therapists will go to an agoraphobic patients home to conduct the initial
sessions. Often therapists take their patients on excursions to shopping malls and other
places the patients have been avoiding. Or they may accompany their patients who are
trying to overcome fear of driving a car.

The
patient approaches a feared situation gradually, attempting to stay in spite of rising
levels of anxiety. In this way the patient sees that as frightening as the feelings are,
they are not dangerous, and they do pass. On each attempt, the patient faces as much fear
as he or she can stand. Patients find that with this step-by-step approach, aided by
encouragement and skilled advice from the therapist, they can gradually master their fears
and enter situations that had seemed unapproachable.

Many
therapists assign the patient homework to do between sessions. Sometimes
patients spend only a few sessions in one-on-one contact with a therapist and continue to
work on their own with the aid of a printed manual.

Often
the patient will join a therapy group with others striving to overcome panic disorder or
phobias, meeting with them weekly to discuss progress, exchange encouragement, and receive
guidance from the therapist.

Cognitive-behavioral
therapy generally requires at least 8 to 12 weeks. Some people may need a longer time in
treatment to learn and implement the skills. This kind of therapy, which is reported to
have a low relapse rate, is effective in eliminating panic attacks or reducing their
frequency. It also reduces anticipatory anxiety and the avoidance of feared situations.

Treatment
with Medications. In this treatment approach, which is also called pharmacotherapy, a prescription medication is used
both to prevent panic attacks or reduce their frequency and severity, and to decrease the
associated anticipatory anxiety. When patients find that their panic attacks are less
frequent and severe, they are increasingly able to venture into situations that had been
off-limits to them. In this way, they benefit from exposure to previously feared
situations as well as from the medication.

The
three groups of medications most commonly used are the tricyclic antidepressants, the high potency
benzodiazepines, and the monoamine oxidase
inhibitors (MAOIs). Determination of which drug to use is based on considerations of
safety, efficacy, and the personal needs and preferences of the patient. Some information
about each of the classes of drugs follows.

The
tricyclic antidepressants were the first medications shown to have a beneficial effect
against panic disorder. Imipramine is the tricyclic most commonly used for this condition.
When imipramine is prescribed, the patient usually starts with small daily doses that are
increased every few days until an effective dosage is reached. The slow introduction of
imipramine helps minimize side effects such as dry mouth, constipation, and blurred
vision. People with panic disorder, who are inclined to be hypervigilant about physical
sensations, often find these side effects disturbing at the outset. Side effects usually
fade after the patient has been on the medication a few weeks.

It
usually takes several weeks for imipramine to have a beneficial effect on panic disorder.
Most patients treated with imipramine will be panic-free within a few weeks or months.
Treatment generally lasts from 6 to 12 months. Treatment for a shorter period of time is
possible, but there is substantial risk that when imipramine is stopped, panic attacks
will recur. Extending the period of treatment to 6 months to a year may reduce this risk
of a relapse. When the treatment period is complete, the dosage of imipramine is tapered
over a period of several weeks.

The
high-potency benzodiazepines are a class of medications that effectively reduce anxiety.
Alprazolam, clonazepam, and lorazepam are medications that belong to this class. They take
effect rapidly, have few bothersome side-effects, and are well tolerated by the majority
of patients. However, some patients, especially those who have had problems with alcohol
or drug dependency, may become dependent on benzodiazepines.

Generally,
the physician prescribing one of these drugs starts the patient on a low dose and
gradually raises it until panic attacks cease. This procedure minimizes side effects.

Treatment
with high-potency benzodiazepines is usually continued for 6 months to a year. One
drawback of these medications is that patients may experience withdrawal symptoms-malaise,
weakness, and other unpleasant effects-when the treatment is discontinued. Reducing the
dose gradually generally minimizes these problems. There may also be a recurrence of panic
attacks after the medication is withdrawn.

Of
the MAOIs, a class of antidepressants which have been shown to be effective against panic
disorder, phenelzine is the most commonly used. Treatment with phenelzine usually starts
with a relatively low daily dosage that is increased gradually until panic attacks cease
or the patient reaches a maximum dosage of about 100 milligrams a day. Use of phenelzine
or any other MAOI requires the patient to observe exacting dietary restrictions,
because there are foods and prescription drugs and certain substances of abuse that can
interact with the MAOI to cause a sudden, dangerous rise in blood pressure. All patients
who are taking MAOIs should obtain their physicians guidance concerning dietary
restrictions and should consult with their physician before using any over-the-counter or
prescription medications.

As
in the case of the high-potency benzodiazepines and imipramine, treatment with phenelzine
or another MAOI generally lasts 6 months to a year. At the conclusion of the treatment
period, the medication is gradually tapered.

Newly
available antidepressants such as fluoxetine (one of a class of new agents called
serotonin reuptake inhibitors), appear to be effective in selected cases of panic
disorder. As with other anti-panic medications, it is important to start with very small
doses and gradually raise the dosage.

Scientists
supported by NIMH are seeking ways to improve drug treatment for panic disorder. Studies
are underway to determine the optimal duration of treatment with medications, who they are
most likely to help, and how to moderate problems associated with withdrawal.

Combination
Treatments. Many believe that a combination of medication and cognitive-behavioral therapy
represents the best alternative for the treatment of panic disorder. The combined approach
is said to offer rapid relief, high effectiveness, and a low

relapse rate. However, there
is a need for more research studies to determine whether this is in fact the case.

Comparing medications and psychological treatments, and determining how well they work in
combination, is the goal of several NIMH-supported studies. The largest of these is a
4-year clinical trial that will include 480 patients and involve four centers at the State
University of New York at Albany, Cornell University, Hillside Hospital/ Columbia
University, and Yale University. This study is designed to determine how treatment with
imipramine compares with a cognitive-behavioral approach, and whether combining the two
yields benefits over either method alone.

Psychodynamic
treatment. This is a form of talk therapy in which the therapist and
the patient, working together, seek to uncover emotional conflicts and gaining a better
understanding of them, the patient is helped to overcome the problems. Often,
psychodynamic treatment focuses on events of the past and making the patient aware of
ramifications of long-buried problems.

Although
psychodynamic approaches may help to relieve the stress that contributes to panic attacks,
they do not seem to stop the attacks directly. In fact, there is no scientific evidence
that this form of therapy by itself is effective in helping people to overcome panic
disorder or agoraphobia. However, if a patients panic disorder occurs along with
some broader and pre-existing emotional disturbance, psychodynamic treatment may be a
helpful addition to the overall treatment program.

When Panic Recurs

Panic
disorder is often a chronic, relapsing illness. For many people, it gets better at some
times and worse at others. If a person gets treatment and appears to have largely overcome
the problem, it can still worsen later for no apparent reason. These recurrences should
not cause a person to despair or consider himself or herself a treatment
failure. Recurrences can be treated effectively, just like an initial episode.

In
fact, the skills that a person learns in dealing with the initial episode can be helpful
in coping with any setbacks. Many people who have overcome panic disorder once or a
few times find that, although they still have an occasional panic attack, they are now
much better able to deal with the problem. Even though it is not fully cured, it no longer
dominates their lives, or the lives of those around them.

Coexisting Conditions

At
the NIH conference on panic disorder, the panel recommended that patients be carefully
evaluated for other conditions that may be present along with panic disorder. These may
influence the choice of treatment, the panel noted. Among the conditions that are
frequently found to coexist with panic disorder are:

Simple
phobias. People with panic disorder often develop irrational fears of specific
events or situations that they associate with the possibility of having a panic attack.
Fear of heights and fear of crossing bridges are examples of simple phobias. Generally,
these fears can be resolved through repeated exposure to the dreaded situations, while
practicing specific cognitive-behavioral techniques to become less sensitive to them.

Social
phobias. This is a persistent dread of situations in which the person is
exposed to possible scrutiny by others and fears acting in a way that will be
embarrassing or humiliating. Social phobia can be treated effectively with
cognitive-behavioral therapy or medications.

Depression.
About half of panic disorder patients will have an episode of clinical depression sometime
during their lives. Major depression is marked by persistent sadness or feelings of
emptiness, a sense of hopelessness, and other symptoms.

When
major depression occurs, it can be treated effectively with interpersonal psychotherapy
and/or antidepressant medication.

Obsessive-compulsive
disorder (OCD). In OCD, a person becomes trapped in a pattern of repetitive
thoughts and behaviors that are senseless and distressing but extremely difficult to
overcome. Such rituals as counting, prolonged handwashing, and repeatedly checking for
danger may occupy much of the persons time and interfere with other activities.
Today, OCD can be treated effectively with medications or cognitive-behavioral therapies.

Alcohol
abuse. About 30 percent of people with panic disorder abuse alcohol. A person who
has alcoholism in addition to panic disorder needs to specialized care for the alcoholism
along with treatment for the panic disorder. Often the alcoholism will be treated first.

Drug
Abuse. As in the case of alcoholism, drug abuse is more common in people with
panic disorder than in the population at large. In fact, about 17 percent of people with
panic disorder abuse drugs. The drug problems often need to be addressed prior to
treatment for panic disorder.

Suicidal
tendencies. Recent studies in the general population have suggested that suicide
attempts are more common among people who have panic attacks than among those who do not
have a mental disorder. Also, it appears that people who have panic disorder and
depression are at elevated risk for suicide. (However, anxiety disorder experts who have
treated many patients emphasize that it is extremely unlikely that anyone would attempt to
harm himself or herself during a panic attack).

Anyone
who is considering suicide needs immediate attention from a mental health professional or
from a school counselor, physician, or member of the clergy. With appropriate help and
treatment, it is possible to overcome suicidal tendencies.

There
are also certain physical conditions that are often associated with panic disorder.

Irritable
bowel syndrome. The person with this syndrome experiences intermittent bouts of
gastrointestinal cramps and diarrhea or constipation, often occurring during a period of
stress. Because the symptoms are so pronounced, panic disorder is often not diagnosed when
it occurs in a person with irritable bowel syndromMitral valve prolapsed. This condition
involves a defect in the mitral valve, which separates the two chambers on the left side
of the heart. Each time the heart muscle contracts in people with this condition, tissue
in the mitral valve is pushed for an instant into the wrong chamber. The person with the
disorder may experience chest pain, rapid heartbeat, breathing difficulties, and headache.
People with mitral valve prolapse may be at higher than usual risk of having panic
disorder, but many experts are not convinced this apparent association is real.

Causes of Panic Disorder

The
following is a description of some of the most important new research on panic disorder
and its causes.

Genetics.
Panic disorder runs in families. One study has shown that if one twin in a genetically
identical pair has panic disorder, it is likely that the other twin will also. Fraternal,
or non-identical, twin pairs do not show this high degree of concordance with
respect to panic disorder. Thus, it appears that some genetic factor, in combination with
environment, may be responsible for vulnerability to this condition.

Brain
and biochemical abnormalities. One line of evidence suggests that panic disorder
may be associated with increased activity in the hippocampus and locus cerelus, portions
of the brain that monitor external and internal stimuli and control the brains
responses to them. Also, it has been shown that panic disorder patients have increased
activity in a portion of the nervous system called the adrenergic system, which regulates
such physiological functions as heart rate and body temperature. However, it is not clear
whether these increases reflect the anxiety symptoms or whether they cause them.

Another
group of studies suggests that people with panic disorder may have abnormalities in their
benzodiazepine receptors, brain components that react with anxiety-reducing substances
within the brain.

In
conducting their research, scientists can use several different techniques to provoke
panic attacks in people who have panic disorder. The best known method is intravenous
administration of sodium lactate, the same chemical that normally builds up in the muscles
during heavy exercise. Other substances that can trigger panic attacks in susceptible
people include caffeine (generally 5 or more cups of coffee are required).
Hyperventilation and breathing air with a higher-than-usual level of carbon dioxide can
also trigger panic attacks in people with panic disorder.

Because
these provocations generally do not trigger
panic attacks in people who do not have panic
disorder, scientists have inferred that individuals who have panic disorder are
biologically different in some way from people who do not. However, it is also true that
when the people prone to panic attacks are told in advance about sensations these
provocations will cause, they are much less likely to panic. This suggests that there is a
strong psychological component, as well as a biological one to, panic disorder.

Help for the Family

When
one member of a family has panic disorder, the entire family is affected by the condition.
Family members may be frustrated in their attempts to help the affected member cope with
the disorder, overburdened by taking on additional responsibilities, and socially
isolated. Family members must encourage the person with panic disorder to seek the help of
a qualified mental health professional. Also, it is often helpful for family members to
attend an occasional treatment or self-help session or seek the guidance of the therapist
in dealing with their feelings about the disorder.

Certain
strategies, such as encouraging the person with panic disorder to go at least partway
toward a place or situation that is feared, can be helpful.

What to do if A Family Member
Has An Anxiety Disorder

Sally
Winston, Psy.D. suggests the following:

1.
Dont make assumptions about what the affected person needs; ask them.

2. Be predictable; dont surprise them.

3. Let the person with the disorder set the pace for recovery.

4. Find something positive in every experience. If the affected person is

only able to go
partway to a particular goal, such as a movie theater or

party, consider that an
achievement rather than a failure.

5. Dont enable avoidance: negotiate with the person with panic disorder to

take one
step forward when he or she wants to avoid something.

6. Dont sacrifice your own life and build resentments.

7. Don't panic when the person with the disorder panics.

8. Remember that its all right to be anxious yourself; its natural for you

to
be concerned and even worried about the person with panic disorder.

9. Be patient and accepting, but dont settle for the affected person being

permanently disabled.

10. Say: You can do it no matter how you feel. I am proud of you. Tell me

what you
need now. Breathe slow and low. Stay in the present. Its not

the place thats
bothering you, its the thought. I know that what you are

feeling is painful, but
its not dangerous. You are courageous.

I
would like to acknowledge the N.I.M.H. Panic Disorder Education Program as the primary
source for this pamphlet.